Bridges Challenge

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What should be UCSF's response to the call for a three year medical school?

Challenge Status: 

Medical education nationwide has a new focus on learning outcomes and the competencies of a graduating medical student. This approach opens the option for medical schools to move away from a time-based, required four years for medical education.

With a shortened degree option, some medical students might go into residencies after three years while others might choose to take a “deep dive” into projects or specialties, but not in the constrained format of medical education today. The New England Journal of Medicine recently posted a point/counterpoint on the issue of the three year medical school curriculum. See Point: A 3-Year M.D. — Accelerating Careers, Diminishing Debt and Counterpoint: The Three-Year Medical School - Change or Shortchange?

As we work to design the Bridges Curriculum for the 21st Century physician, we turn to our community to ask your thoughts on the three year curriculum debate. Should UCSF work to design a curriculum in which students could complete all required rotations (including subinternships) in three years? If so, what would be our main goals of that curriculum: the opportunity for students to complete their education earlier or to take deeper dives into more individualized content? What would have to be in place so that we are confident that our graduates are still expert? How might you envision compressing the existing curriculum to make this happen? We welcome your thoughts on these and any other questions about shortening training in medical school.

Challenge closed as of December 12, 2013. Thank you for your ideas!


We have summarized the results into three key findings:

  1. Themes for which there was consensus among respondents regardless of whether they agreed with whether UCSF should have a three-year medical school
  2. Themes from those who either supported or did not support the notion of a three-year medical school and reasons why
  3. Suggestions respondents suggested should be considered in developing a three-year medical school

See details


This is a thought-provoking proposal.  I think one way to achieving a three-year medical school is to have second-year preceptorships completed during the summer.  The student would go on a daily basis for a period of 2-3 weeks in the summer, to a clinical setting. 

Currently, second-year students complete a total of 28 hours of preceptorship sessions spread throughout a 4-month period (August through December).

By 'compressing' the sessions to a 2-3 week period in the summer, the students will have more time to advance on other subjects.  A similar solution could be applied to 3rd-year students in Longitudinal Clinical Experience (LCE) preceptorships program.


The authors of the NEJM article in favor of a three-year MD assert that the shortened program will lead to a reduction in student debt burden.  I believe this assertion is incorrect.

In fact, a three-year training program will be more attractive to students pondering a career in medicine, so the demand for medical training will rise.  When demand for something rises, but supply remains fixed, the cost goes up, not down.  There might be a temporary period where the three-year MD is less costly, but over the long run prices will equilibrate according to supply and demand. 

One might say that stewards of public institutions will commit to keeping per-year tuition low, and so the actual cost of a three-year program at public institutions will remain low compared to the four-year program.  But this, too, misses the larger picture.  We have a lot of private institutions of education in this country, which is another way of saying that market forces rather the decisions by public administrators are what largely determine the average price of education.  

To see why this is the case, it may be helpful to partially sketch out the mechanism of price equilibration in our mixed public-private system.  As a result of price controls at public institutions, the capacity of medical school classes at public schools will grow more slowly than the capacity of classes at private institutions that do not face the same revenue constraints.  Over the long term, the number of such spots will decline in comparison to the number of spots at private schools, and there will be increased competition for the relatively small number of spots available at public schools where tuition is controlled.  Ultimately, the overall debt burden will increase as more students attend expensive private institutions.

The outcome might be different if there were very few private institutions and if higher education were provided largely by the state, as it is in many other countries.  But in our country we have a very large private market in education.  As a consequence, the state is largely unable to set prices, except by acting through the channels of supply and demand. 

How to control the cost of education is a discussion for another day, given that this forum is about the three-year MD.  To be clear, I think the question of a three-year MD is an interesting one that deserves discussion.  But the NEJM authors might have acknowledged that the price of education is largely a function of market forces, and that the three-year MD, if designed as an equivalent to the four-year program in terms of rigor, is likely to raise the cost of education, not lower it.  In order for the three-year degree to truly provide cost savings, it would ultimately have to be a less valuable/less desirable product than the four-year degree, or there would have to be a much larger market restructuring involving increases in the supply of UME and GME training positions.

Duke does this in a way - they have a 3 year curriculum but then require a 4th year of research or additional course work in lawy, business, public health, etc. They  compress the preclinical coursework and clinical experience into 3 years by eliminating most of the summer time for electives/experiential exploration.

Going to 3 years means giving up an opportunity to explore other interests during the summer between 1st and 2nd year as well as time for electives. I can see the economic motives for this. It is still not cldar to me if you are still going to want 4 years but will have a full year to do a "deeper dive", the way Duke does it, or will you allow people to graduate in3 years and go right into residencies?  I worry that the students will not be adequately prepared for residencies without some time to practice as 4th year students and gain maturity and  knowledge.



i agree with the sentiment that the additional clinical trainig time that comes with the fourth year has a lot to add. UCSF students, more so than other schools nationally, believe that their fourth or final year was important in enhancing their clinical education. This means we are doing something right with the that final year that we will want to retain even if we move to a three year  curriculum. it maybe that we would need to understand better which clinical experiences our students have found useful and ensure that we build opportunities for those into a three year plan at the relinquishment of something else....

I anticipate many thoughtful comments. I would like to highlight that I have found that UCSF functions well with options available for learners. So mindful of challenges already pointed out, I would support that an individual with quality advising could opt to forego the fourth year. I actually think this will be a small number of our students. However, I think this is an important opportunity for residencies to be innovative as to how they might transition a third year student to internship. Plans for this will give serious consideration to the concept of "continuum" in medical education.

Adding a three year option only works if there are robust assessment measures, clear milestones, strong career advising and motivated students.  This option is consistent with our Carnegie recommendation to standardize on learning outcomes and individualize the learning process. 

Outcomes from three year programs are identical to that of four year programs.  Thus, the fourth year should offer other opportunities that might entice our students to continue through the four years (such as the Pathways to Discovery Program, joint masters degree programs, and other elective opportunities). Currently, 40% of our students take longer than four years so I don't anticipate that the three year option will be a large pathway. But, it will be an important pathway because it demonstrates our commitment to personalized education and flexible programs.

If there are clear, robust and transparent assessment strategies, it makes sense that medical school should be competency based and not time-based.  With such an approach, a 3 year curriculum could make sense for a motivated and competent medical student with clear goals for their learning/career.  Given this transition, however, there should be preparation for extending medical school for those that do not reach competency and adequate faculty development in assessment to ensure competency is assessed appropriately.  

I think increasing flexibility by shortening to a 3-year program could be a great option for students selecting a career in one of the core clerkship disciplines, but would be challenging for those interested in a specialty not otherwise represented. As discussed in the NEJM papers, this would only be realistic for students continuing at the same institution for residency (or at a different institution also offering a 3-year program).

If the larger goal in creating the 3-year curriculum is to shorten the total time before beginning practice (and reduced number of years accruing debt), praticularly in fields that have very long training processes (i.e. 6-7 year residencies with 1-2 year fellowships to follow), will the 3-year option actually have the desired impact? Would the directors of those training programs at our institution welcome these students into a coveted position without time to do research or additional study? I worry that the program would only shorten the process for students choosing a more general discipline, which would have a lower impact on the larger goal.

I think it would be critical to involve UCSF residency program directors in the discussion to ensure they will support excellent students in this pathway. They are key stakeholders who will influence the success (or failure) of the short track.


My other comments/questions are more logistical--

A seamless process for converting to a 4-year program if a student's goals or readiness change would be critical. Logistically, it sounds quite challenging to create a personalized compressed program that remains flexible enough to accommodate dynamic change. At what timepoints would the change be possible? Would the converted student rejoin the 4-year curriculum "off-cycle"? If they have a more compressed "pre-clinical" curriculum, would faculty have to teach adapted courses twice a year? This may be acceptable to core SOM education faculty, but what about all of the additional apprenticeship experience faculty? How would the timing of USMLE Step 1 and 2 fit in with a 3-year model?


I am certainly no expert in the field and would simply add that I do like the consistency of competency and outcome based assessments as opposed to a simple time based graduation policy. I do not like the idea of the cost of education being a major factor in determing duration of training.  I support a minimum duration regardless of competencies gained.  This would be necessary not just for the sanity of those making schedules but also to enusre adequate exposure to role models and life experiences regardless of medical competencies gained.  Similarly, perhaps a maximum duration where further training is unlikely to be of benefit and can therefore be terminated.

I am not convinced by the argument for a purely 3 year curriculum.  As has been mentioned in prior comments, the critical advancement that must be acheived before this takes hold is a robust, valid and flexible assessment process.  The current state of assessment is not up to the task as subjective assessments are not completed with adequate care and objective assessments are limited to medical knowledge domains.


I strongly advocate a flexibly timed curriculum, that allows learners to progress at their own rate and develop skills that they value.  The logistical challenges of this approach are monumental and would require a deep embrace of competency and objective based education (as opposed to simple mapping of objectives to pre-existing material).


The current siloing of the pre-clinical and clinical curricula is a major driver of the length of medical school.  The content that medical students learn in lecture halls could easily be encorporated into the clinic (and might reduce student temptation to volunteer for scutwork that does not impact their learning but may bolster evaluations).

How is moving to a 3 year curriculum any more justified than a 4 year curriculum when the ultimate goal is to prepare learners for the next phase of their training (residency, research, industry, etc) through the achievement of well-thought out, validated, benchmarks/milestones? If this is true, could it not be the case that some learners would meet these goals before 3 years have elapsed (the "new" time-based curriculum in a sense). Should medical students be allowed to test out of pre-clinical courses if they have had the exposure elsewhere (undergrad coursework, for example)? The logistics here are mind-boggling of course since much of the current coursework is sequential in nature such that simply testing out of a given subject wouldn't necessarily translate into a more rapid transit through the curriculum (since a given course might only be offered once per year, etc). Asynchronous learning options would potentially be a pivotal part of this.


I support the flexibility of 3- or 5-year options for students, depending on their interests and their demonstrated expertise.  There are opportunities to build early clinical experiences into the curriculum, allowing some students to identify and pursue early differentiation into a subfield.  There is an additional opportunity for a didactic, and potentially interprofessional, summer quarter.   Some of the costs of education are fixed costs - should the physical therapy students be the sole occupants of fixed cost university classrooms during the summer?  Although many medical students participate in educational experiences during the summer quarter, the UME curriculum schedule could be altered from the current undergraduate model to a graduate level, year-round educational model. 

Very interesting discussion!  I think individualized pathways make sense, presuming robust assessment strategies are in place-- including assessments related to maturity and professionalism.   Even though there is currently a lot of compartmentalization between undergraduate studies, a student's next endeavors if they don't go straight to medical school, UME, and GME, I think it is also important to re-examine the full educational continuum.   Is it crucial for all future doctors to take a year of organic chemistry?   Could that time be better spent pursuing a research (or other interest) with a scholarly approach to learn evidence-based medicine and critical appraisal skills?  It would be wonderful to build a transitional MS-IV-internship year that maximizes educational opportunities and minimizes noneducational scut work and "extraneous load."  Are there alternative ways to fund medical education so that debt burden doesn't influence career trajectories as much?  

Overall, I am in favor of the idea of an individualized pathway in medical education.  Lengthier pathways (i.e., 5+ years) are already in place somewhat, as students will often extend their UME years by taking a year of research, a year to do a masters degree, etc.  I remember several members of my medical school class at UCSF "splitting" their MS2 year into two years to enable more time to focus on the difficult academics. (Not sure if that is still an option here . . .?). 

Extension of medical school is, of course, easier than shortening it.  As reiteratedin the comments below, regular, thorough assessments and close tracking of students needs to occur for this to work and ensure we are producing learners prepared for intern year, academically, psychologically and professionally.  I also agree with Nina that this is much more likely to work for those entering less competitive specialties and planning to stay at their home institutions. 

Ways to compress the curriculum as it stands now, could involve eliminating the summer between 1st and 2nd years, decreasing the length of various core rotations (for example, I know some medical schools only have a 3 week pediatrics rotation) and eliminating fourth year electives.  The question is what curriculum changes do you apply universally to all medical students and what to simply the "fast-trackers"? The more curriculum pathways, the more money, admin time and faculty involvement needed, which could be problematic.

I do find the idea exciting, though!

We should embrace this concept. Recently at a meeting with Rep Pelosi's staff, we learned that they would very much like to see some way of reducing the burden of cost of medical education. This certainly would address that, as well as get our students to achieve their goals at an earlier age. We have much success to review from the 6 year programs and knowledge to gain from that experience.

Interesting conversation. I recognize the economic pressures and why a 3-year curriculum would be valuable but I would hate to see clinical experience shortchanged. The preclinical curriculum is a carefully crafted program - clinical experience is much harder to control, sinceit depends to a great extent on which patients happen to come in when a student is on each rotation. I recognize that thre are important competencies that can be learned from ANY patient but there are also some very special experiences that come only with certain, special patients, and it is really hard to predict and program for these. Cutting clincal time even more makes it less and less likely that a student wl encounter these highly formative experiences.

From a coordinator perspective, I think logistically a 3-year cuuriculum may not be the best use of resources because creating individualized schedules and tracking individualized assessments to allow students to graduate in 3 years will require significantly more faculty and coordinator time, and thus increase the cost per year/per student of medical school. 


Also, I think that non-clinicians often forget what Dr. Nussbaum said, "The preclinical curriculum is a carefully crafted program - clinical experience is much harder to control, sinceit depends to a great extent on which patients happen to come in when a student is on each rotation. I recognize that thre are important competencies that can be learned from ANY patient but there are also some very special experiences that come only with certain, special patients, and it is really hard to predict and program for these. Cutting clincal time even more makes it less and less likely that a student wl encounter these highly formative experiences."


I think we need to balance the kind of physician we want to develop, with the MD program duration, with costs, and our resources (facutly and staff time, and clinical opportunities/number of patients), rather than let any one of these drive the new curriculum.



I have very much enjoyed the back and forth of this debate, and see great arguments on both sides. One unorthodox idea along these lines is why does medical school need to be set to a year requirement? Whether that requirement be 3-years or 4-years? If, as Dr. Irby and Dr. Laponis pointed out so well, if there are transparent, well delineated competencies, a very motivated student should be able to travel through the currciulum at a speed that is befitting of their goals, aspirations, temperment, and abilities. 


I think a 3-year or shortened medical school is more feasible now than ever. As many have pointed out, Duke has essentially been doing this for many years. Ohio State operates a "self-directed" track in which students do the majority of their learning on their own. As online learning tools improve, and on-line learning gains more acceptance, the ability to direct one's own learning, and to progress at variable speeds will be far greater.


On the other hand, while I think this is an interesting question, I can already poke many holes in my own arguments, many of which have been addressed in others comments. Being a medical resident, I know very little about the organizational side of medical education, and I can see how something like this could pose some impressive logistical obsticles. Scheduling exams, clinical rotations, and graduation ceremonies would be quite the challenge. Additionally, I am proud of the steps that the ACGME have taken to ensure duty hour restrictions in an attempt to improve resident wellness, health, and patient safety. Allowing medical students to barrel through the curriculum "at their own risk," could present many wellness issues. And lastly, something I don't recall seeing mentioned, the camraderie of the medical school experience would take quite a blow if everyone was taking the curriculum on individually. Having completed medical school recently myself, I look back on my time fondly, mostly for the experiences shared with others, tackling obstacles as a united class.


There were certainly times in medical school when I felt the curriculum could have made better use of my time, or thing could have been more condensed. But would I have lost some of the structure? Or would I have lost the supportive and caring enviroment in which I was able to learn? Or perhaps I would have lost the camraderie, the piece I will remember with the most nostalgia? A three-year curriculum has potential cost benefits, and benefits of time efficiency, but what would we be giving up?


Adding on to all of the excellent comments below, there are clearly many advantages and disadvantages of a 3 year curriculum. Other medical schools have experimented with this change, and many residency programs offer a residency analog of a 3 year medical school curriculum called “fast tracking” in which residents can forgo some years of their residency so as to enter into a fellowship early. Just like “fast tracking” is an option for a minority of motivated residents in certain residency programs, a 3 year medical school could be an option for a minority of motivated medical students at UCSF.

If UCSF were to create such a “fast track” for medical school, there would need to be several safe guards in place so as to ensure that the graduates UCSF produces are both medically and professionally ready to become physicians as well as to ensure their mental well being with such an accelerated schedule. In regards to proving medical and professional readiness to become a physician, a series of core competencies that others have alluded to could serve this goal. Mental well being would be much harder to document with a core competency. Ideally, there would be a robust advising system established for those students choosing to pursue a fast track, and there would be multiple opportunities for students to “opt out” of the “fast track” and revert to a more traditional curriculum in case of medical student burnout, lack of medical student preparedness and/or second thoughts re: future career paths.

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Developing Habits of Mind in Inquiry

Challenge Status: 


Since March, the Bridges Curriculum design teams have identified the importance of students developing the habits of mind in inquiry as key attributes of the 21st Century Physician. Habits of mind in inquiry include the knowledge, skills and attitudes that are used to approach problems when solutions are not readily apparent or don't exist. The Bridges physician should have the ability to tackle complex problems in the health sciences in order to improve health and our systems of care. 


It has been proposed that we teach inquiry across six domains of science critical to development of a UCSF physician, these are identified as:

  • Biomedical science
  • Clinical science
  • Population science & public health
  • Pedagogical science
  • Social and behavioral science
  • Systems science


Bridges Challenge: 

Given these recommendations how might we teach, support and assess inquiry as habits of mind in the core UCSF MD curriculum? 


Your recommendations might include teaching and learning strategies, frameworks for assessment, administrative structures for support, processes for how students could take a "deep dive" into one of the six domains of science. 



This is a great innitiative that will (hopefully) address a number of issues undergraduate medical education has been grappling for some time. Here are some things we might start with to get the conversation going.

These are three areas I am using to organize my thoughts around:

1) Students must constantly assess and reassess  their understanding of the problems in the areas listed in the Challenge. I think of it in terms of addressing the folloawing questions: a) What do I know/understand? b)What do I don't know/understand? c)What do I need to know/understand?

2) Students must continuously work on expanding of understanding and assessment of resources used to expand their understanding. a) Where do I go to get the information I need? b) How do I assess the validity/veracity/value of the source and the information c) What are the questions that are important but have not been answered?   

3) Students must communicate information to colleagues and patients. a) How do I communicate necessary information effectively and concisely to individuals? Groups?

Small group discussion is the setting that, in my opinion, would best address the learning process in these areas. Students would be presented with a problem, given some guidelines (for example, the question: What do I know?, What do I don't know?...) and asked to come up with one information source of their own choosing to present in class (brief presentation). With the help of the discussion leader(s) they would discuss each of the presentations (not more than 3/hour) for both content and communication.  The leaders would lead the discussion using Socratean method and students would be expected and encouraged to question eachother's assertions and conclusions as well as asertions and conclusions from the sources students used to present. To help leaders lead fruitful discussions the class should be based (at least mostly) on the problems with known answers, but selected so that they match the curricular content/block they are currently working on. This would also provide incentive for students to prepare and could be used to effectively cover some of the curricular content. 

As they progress through the Inquiry curriculum, the students' understanding of the inquiry process would mature sufficiently to have them start formulating their own questions they could address in the "Deep Dive" component of the Inquiry curriculum. Each student would prepare a small proposal that would address a current problem that we do not have answer to in one of the areas (from biomedical science through systems science) listed in the curriculum. Each proposal would be presented in the small group and it would be evaluated by the small group leader. This would also serve as the assessment of their competence in the Inquiry curriculum at this stage of learning.  



Also, assessments could (perhaps should) also be done in the form of an essay/short "open book" question. The question would cover the material not taught or otherwise covered and students would have access to internet in order to answer it. 

Commenting is closed.